Last weekend the Nuts & Bolts team (except cats!) went to the cinema to watch the new film about the early life of J.R.R Tolkien. I have been a fan of Tolkien since reading The Hobbit at the age of 5 years old and The Lord of the Rings when I was 6… okay this is early to read this book; I didn’t understand much of the dark bits but I was captured by the heroic story and have read it again many times since… the ECIC cannot understand this, she thinks it’s weird to read a book when you already know how it’s going to end… maybe she’s right, but that won’t stop me, where did I leave my copy, or my second copy or that third copy or…
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Surely you can’t connect Tolkien with microbiology!? Read on to find out more…

​Tolkien enlisted in the Lancashire Fusiliers and was sent to the Western Front in June 1916 to join the Somme offensive. He was assigned as a Lieutenant in the signal corps and put in charge of enlisted men; there is a great quote from him, "the most improper job of any man... is bossing other men, …not one in a million is fit for it, and least of all those who seek the opportunity”… a sentiment I share.

“We have a young child with a fever and a rash who isn’t very well and we want to test for measles” said the Junior Doctor working in Paediatrics.
 
“Have they been vaccinated?” asked the Microbiologist in reply.
 
“No, their Mum was worried about the vaccine and so they haven’t had it done” was the response.
 
“Do they have any spots in their mouth?” asked the Microbiologist.
 
“They don’t have any spots, it’s not Chicken Pox it’s more like measles…” replied the Doctor sounding confused.
 
“They’re called Koplik spots, maybe get a Consultant to have a look. Is the child isolated?”
 
“Errrmmmm…” replied the Doctor “I don’t think so…”
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The patient is a young female who presented with a very high fever of 40.5oC, lethargy and not eating. The past medical history included dislocated knees due to a congenital problem requiring surgery to relocate and reconstruct the patella groove. She is not taking any regular medication, has not been in contact with anyone else who is unwell and has not travelled out of the UK.
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Essentially this is a case of pyrexia of unknown origin or PUO. What is PUO and what should you do about it?

“I think my patient has syphilis” said the GP.
 
“Why do you think that?” asked the Microbiologist.
 
“Well, they have a funny skin lump and I had read recently that syphilis can mimic any other type of infection and that it’s making a comeback and so I did the test and it’s positive!”
 
The Microbiologist groaned to himself.
 
“Let me have a look at the results as well” he said.
 
To the Microbiologists surprise the patient did have positive syphilis serology.

“Where is the patient from?” the Microbiologist asked.
 
“What do you mean? They live locally” answered the GP.
 
“I mean where were they born? Have they lived abroad?”
 
“Oh, I don’t know. Why does it matter?”
 
“Can you give them a call and find out then call me back. This could be Yaws, Pinta or Bejel” replied the Microbiologist.
 
“Sorry my what? …Your's a pint of what…and a bagel? What did you say? This line is really bad” said the GP getting increasingly confused.
 
“Find out where they have been and call me back and then I’ll explain further” answered the Microbiologist.

The mother was frantic.
 
“I don’t know what happened” she cried to the Paediatrician, “he was just a bit irritable when I put him to sleep last night and had a bit of redness around his mouth, but this morning his skin is falling off!” She then dissolved into floods of tears.
 
The Paediatrician took one look at the blisters and broken skin around the baby’s umbilicus and nappy area and asked “could he have been scalded with hot water at all? He looks burnt!

“Can I discuss an unwell baby?” asked the Neonatal Registrar.
 
“Of course, what’s the story?” replied the Microbiologist.
 
“We have a baby who is just over 24 hours old. They were born at term in good condition but started to grunt and looked mottled by 4 hours. We brought them to the Neonatal Unit, did blood cultures and started IV Benzylpenicillin and Gentamicin as per guidelines but they’re not really improving. Do you think we need to change the antibiotics? Has anything grown in the blood culture?”
 
The Microbiologist chose to ignore the last question as blood cultures are incubated in an automated incubator which scans the bottles every 10 minutes. If the blood culture where positive then it would have been phoned already.
 
“Is the baby’s mother okay? Have there been any problems during the pregnancy. Was the mother fully vaccinated? Was the labour normal? Is there anything else you’ve noticed about the baby, any odd lumps, bumps or spots?” asked the Microbiologist.

Hospital acquired infections are never a good thing, usually there is simply lapse in care, resources or common sense behind most occurrence. The normal kinds of infection you “expect” to see being acquired in hospitals are MRSA, Norovirus or Clostridium difficile. However sometimes outbreaks can be a real mystery to solve. I have had to deal with an unusual outbreak of hospital acquired fungal infection myself, so I was intrigued to “read on” when I saw this week’s headlines that “a strange outbreak had occurred in a Scottish hospital”.
 
This outbreak occurred at the Queen Elizabeth University Hospital in Glasgow and sadly patients have died as a result. An outbreak is defined when there are two or more cases linked in time, place or person. A single infection can constitute an outbreak if the infection is significantly rare or unlikely in the particular situation. The Glasgow outbreak is unusual in that it is not the normal kind of infection you expect to see being acquired in hospitals, this was cryptococcosis.
 
Cryptococcosis is a fungal infection caused by yeast like organisms of the family Cryptococcus spp. There are three main subspecies which infect humans:

• Cryptococcus neoformans var. neoformans
• Cryptococcus neoformans var. grubii
• Cryptococcus gatii

 
Cryptococcus spp. are found worldwide and throughout the environment; C. gatii is mainly found in the tropics whereas C. neoformans is more common and widespread. C. neoformans is principally found in pigeon droppings and pigeon nests as well as soil whereas C. gatii tends to be found in the bark of trees as well as soil. Other animals have been known to carry Cryptococcus spp. including cats, dogs, horses and even camels, llamas and alpacas!

​The Microbiologist was sat at his desk Boxing Day morning authorising out results and waiting for some further work on the blood cultures before ringing them out when his oncall mobile phone went off.
 
“Hi, it’s the ED Registrar here; can I discuss a patient with you?”
 
“Of course, what have you got” answered the Microbiologist.
 
“We’ve got a chap who has recently been abroad and has presented with a fever and feeling unwell. The basic story is that he returned home from work in the early hours of this morning looking flushed and tired. His wife was worried about him, as his belly was rather distended, so persuaded him to come to the hospital. He insists this is how he normally feels at this time of year but his wife isn’t convinced.”

The patient was a young man in his early 20s. He presented to the Emergency Department with pain in his neck and difficulty swallowing. He managed to tell the ED Doctor that he had had a bad toothache for over a week but had been putting off seeing a Dentist because “he had too many other things to do”.
 
On examination he was febrile and tachycardic and his respiratory rate was high. The ED Doctor could see that his neck was swollen even by looking from the end of the bed.

“I have a 3 year old patient with an infected ulcer on their leg which is proving particularly difficult to treat” was the opening statement from the Surgeon.
 
“What antibiotic are you giving?” asked the Microbiologist in a surly tone, thinking this was going to be a simple case of wrong antibiotic.
 
“I’ve been using Co-amoxiclav, but it doesn’t seem to be getting better” was the reply.
 
“Have you sent any samples to the lab?”
 
“I swabbed the wound and the result has come back showing a Coagulase-positive Staphylococcus; I wonder if this might be Staphylococcus pseudintermedius or possibly Staphylococcus aureus” said the Surgeon.
 
“Staphylococcus aureus is the most common bacterium we see in this situation” answered the Microbiologist, “why do you think it might be Staphylococcus pseudintermedius?”
 
“In our patients Staphylococcus pseudintermedius is often grown from these types of samples…oh, I forgot to mention, I’m a Veterinary Surgeon and the 3 year old patient is a Husky” was the reply…. “I should say too that the bacterium is resistant to beta-lactams… according to the report…